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Response to: ‘Tocilizumab in patients with adult-onset Still’s disease refractory to glucocorticoid treatment’ by Lee
  1. Yuko Kaneko1,
  2. Hideto Kameda1,2,
  3. Kei Ikeda3,
  4. Tomonori Ishii4,
  5. Kosaku Murakami5,
  6. Hyota Takamatsu6,
  7. Yoshiya Tanaka7,
  8. Takayuki Abe8,
  9. Tsutomu Takeuchi1
  1. 1 Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
  2. 2 Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
  3. 3 Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
  4. 4 Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
  5. 5 Department of Rheumatology and Clinical Immunology, Kyoto University, Kyoto, Japan
  6. 6 Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
  7. 7 The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
  8. 8 Department of Preventive Medicine and Public Health, Biostatistics at Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
  1. Correspondence to Dr Yuko Kaneko, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; ykaneko{at}

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We would like to thank Dr Lee1 for his interest in our paper2 and for his comments providing futuristic insights into the management of adult-onset Still's disease. As he highlights, conventional disease-modifying antirheumatic drugs (DMARDs) are important options for this disease.3–5 Although the safety of biological agents including tocilizumab have been shown in patients with rheumatoid arthritis, they are more expensive than conventional DMARDs, and the long-term safety of their use in patients with adult-onset Still's disease is still unknown. Some of patients in our trial had a history of not responding to DMARDs such as methotrexate or ciclosporine, but we did not collect precise information about patients’ previous treatment other than glucocorticoids use.

Our trial was a first step, aimed at proving the efficacy of anti-interleukin-6 treatment by a high-levelled evidence rather than case reports. As Dr Lee mentioned, further randomised studies are warranted to determine the optimal management of adult-onset Still's disease, although the rarity and occasional fatal severity of adult-onset Still's disease would hinder determining appropriate endpoints and recruiting active patients who are refractory to glucocorticoids but can tolerate control treatment including placebo or conventional DMARDs. The next step will need worldwide cooperation to establish the optimal management of adult-onset Still’s in clinical studies with a proper design and sample size.



  • Handling editor Josef S Smolen

  • Contributors This is a reponse to e-letter.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Commissioned; internally peer reviewed.

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